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  • 1
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    Anterior choroidal artery ischaemic patterns predict outcome of carotid occlusion
    BMJ ; 2012
    In:  Journal of Neurology, Neurosurgery & Psychiatry Vol. 83, No. 6 ( 2012-06), p. 586-590
    Details
    In: Journal of Neurology, Neurosurgery & Psychiatry, BMJ, Vol. 83, No. 6 ( 2012-06), p. 586-590
    Type of Medium: Online Resource
    ISSN: 0022-3050 , 1468-330X
    URL: Article
    DOI: 10.1136/jnnp-2011-301493
    RVK:
    XA 10000
    Language: English
    Publisher: BMJ
    Publication Date: 2012
    detail.hit.zdb_id: 1480429-3
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  • 2
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    Elucidating the Mechanism of Posterior Reversible Encephalopathy Syndrome : A Case of Transient Blindness After Central Venous Catheterization
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  The Neurologist Vol. 18, No. 6 ( 2012-11), p. 391-394
    Details
    In: The Neurologist, Ovid Technologies (Wolters Kluwer Health), Vol. 18, No. 6 ( 2012-11), p. 391-394
    Type of Medium: Online Resource
    ISSN: 1074-7931
    URL: Article
    DOI: 10.1097/NRL.0b013e31826a9954
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
    detail.hit.zdb_id: 2070987-0
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  • 3
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    Optimized Hemodynamic Assessment to Predict Stroke Risk in Vertebrobasilar Disease: Analysis From the VERiTAS Study
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Journal of the American Heart Association Vol. 9, No. 12 ( 2020-06-16)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 9, No. 12 ( 2020-06-16)
    Abstract: Atherosclerotic vertebrobasilar disease is a significant etiology of posterior circulation stroke. The prospective observational VER i TAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) study demonstrated that distal hemodynamic status is a robust predictor of subsequent vertebrobasilar stroke risk. We sought to compare predictive models using thresholds for posterior circulation vessel flows standardized to age and vascular anatomy to optimize risk prediction. Methods and Results VER i TAS enrolled patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis/occlusion in vertebral and/or basilar arteries. Quantitative magnetic resonance angiography measured large‐vessel vertebrobasilar territory flow, and patients were designated as low or normal flow based on a prespecified empiric algorithm considering distal territory regional flow and collateral capacity. For the present study, post hoc analysis was performed to generate additional predictive models using age‐specific normalized flow measurements. Sensitivity, specificity, and time‐to‐event analyses were compared between the algorithms. The original prespecified algorithm had 50% sensitivity and 79% specificity for future stroke risk prediction; using a predictive model based on age‐normalized flows in the basilar and posterior cerebral arteries, standardized to vascular anatomy, optimized flow status thresholds were identified. The optimized algorithm maintained sensitivity and increased specificity to 84%, while demonstrating a larger and more significant hazard ratio for stroke on time‐to‐event analysis. Conclusions These results indicate that flow remains a strong predictor of stroke across different predictive models, and suggest that prediction of future stroke risk can be optimized by use of vascular anatomy and age‐specific normalized flows.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.120.016406
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 2653953-6
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  • 4
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    Abstract WP140: Imaging of Clot Porosity Prior to Endovascular Thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background: Clot characteristics and porosity at the proximal portion of an arterial occlusion may influence potential recanalization. Thrombus permeability may be a factor in intravenous thrombolysis, whereas such features of clots prior to endovascular thrombectomy remains largely unexplored. We developed a technique to image clot porosity and yield quantitative measures that may predict mechanical recanalization. Methods: Consecutive cases of large artery occlusion (ICA or proximal M1 MCA) with single-phase CT angiography (CTA) acquired immediately prior to endovascular thrombectomy were analyzed. 3D-reconstruction, vessel segmentation, centerline extraction, signal intensity gradient calculations and surface mapping of CTA yielded porosity images and quantitative measures. Porosity measures were correlated with angiography parameters and procedural details. Results: 53 consecutive cases of acute stroke with contemporaneous sCTA and DSA were used to generate porosity images. Technical limitations precluded image processing in 9 cases, due to diminished contrast conspicuity in close proximity to bone interfaces. Porosity features on resulting images and the quantitative measures of clot penetration varied markedly, even within the subset of M1 or ICA occlusions, respectively. The occlusions often exhibited long segments (mean 18 ± 11 mm) of luminal narrowing before complete occlusion. Current analyses examine whether higher porosity or greater proximal contrast penetration of the clot is associated with faster recanalization and fewer device passes during endovascular thrombectomy. Conclusions: Clot porosity images and quantitative measures of proximal contrast penetration may be generated from routine CTA. Imaging of clot porosity may be a useful adjunct in planning of endovascular procedures and future strategies may focus on distinguishing atherosclerotic versus thromboembolic large artery occlusions.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.wp140
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 5
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    Abstract TP113: Intracranial Atherosclerotic Stenosis Prevalence in a North American Stroke Population
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background and Purpose: Intracranial atherosclerotic stenosis (ICAS) is a common cause of stroke especially in Asia, but little is known about its prevalence in ischemic stroke patients in North America. We studied the prevalence of ICAS in a single comprehensive stroke center leveraging the routine acquisition of MRI and MR angiography (MRA). Methods: We retrospectively reviewed patients with ischemic stroke and transient ischemic attack who were admitted within seven days of onset from Jan 2014 to July 2016. Patients we excluded: 1) Age 〈 18 years; 2) without intracranial angiography; 3) overt cardiogenic occlusion or risk factors. Data were retrieved including demographics, vascular risk factors, brain imaging including MRA, CTA, and /or DSA, and prior medical prevention of stroke. ICAS was defined as the proximal atherosclerotic stenosis or occlusion ≥50% in diameter. We estimated the prevalence of ICAS at this single stroke center. Results: 685 included patients were aged 20 to 101 years, 384(56.1%) were men, 520 (75.9%) were white, and 74(10.8%) were black. ICAS was prevalent in 41.6% of all included patients. Univariate analysis indicated that the prevalence of ICAS was significantly increased along with age, it was 39.3% for 41-60 years, and 43.8% for 61-80 years (P=0.034). But no significant difference was found between different races, it was 40.8% in Whites, and 40.5% in Blacks, and other races were 47.3%. Patients with ICAS had more severe stroke (NIHSS 〉 3 vs NIHSS≤3: OR 2.729; 95%CI: 1.748-4.260; P 〈 0.001). Higher levels of high-density lipoprotein cholesterol were associated with decreased odds of ICAS (OR 0.981; 95% CI: 0.968-0.995; P 〈 0.006). Our data did not show hypertension, dyslipidemia and body mass index and smoking were associated with ICAS. Conclusions: The prevalence of ICAS in North America may be much higher than previous estimates. The impact of this common cause of recurrent stroke warrants further study, even in populations were cardiogenic embolic risk is common.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.tp113
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 6
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    Abstract 170: Impact of Eloquent Motor Cortex-Tissue Reperfusion Beyond the Traditional TICI Scoring After Thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Background: Targeted eloquence-based tissue reperfusion within the primary motor cortex may have differential effect on disability as compared to the traditional volume-based (TICI) reperfusion after endovascular thrombectomy (EVT) in setting of acute ischemic stroke (AIS). Methods: We explored the impact of eloquent reperfusion (ER) within primary motor cortex (PMC) on clinical outcome (mRS) in AIS patients undergoing EVT. ER was defined as presence of flow on final digital subtraction angiography (DSA) within four main cortical branches, supplying the PMC (MCA - precentral, central, anterior parietal; ACA- pericallosal) and graded as absent (0), partial (1), and complete (2). Prospectively collected data from two centers were analyzed. Multivariable analysis was conducted to assess the impact of ER on 90-day disability (mRS) among patients with anterior circulation occlusion who achieved partial reperfusion (TICI 2 a and b). Results: Among the 125 patients who met study criteria, median age was 73, median NIHSS was 16, median ASPECTS was 7, 48% (60/125) were female, and 36.8% achieved functional independence (mRS 0-2) at 90 days. ER distribution was: Absent (0) in 19/125 (15.2%); Partial (1) in 52/125 (41.6%), and Complete (2) in 54/125 (43.2%). TICI 2b was achieved in 102/125 (81.6%) and ER was substantially higher in those patients (p 〈 0.001). In multivariate analysis, in addition to age and sICH, ER had a profound independent impact on 90-day disability (OR 6.10, p=0.001 for ER 1 vs 0; and OR 9.87, p 〈 0.001 for ER 2 vs 0). In contrast, extent of total partial reperfusion (TICI 2b vs 2a) was not related to 90-day disability. Conclusions: Our findings support that eloquent PMC-tissue reperfusion is a major determinant of functional outcome, more impactful than volume-based degree of partial reperfusion. More aggressive, PMC-targeted revascularization among patients with non-eloquent partial reperfusion may further improve post-stroke disability after EVT.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.170
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 7
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    Abstract WP174: Frequency, Predicators, and Outcomes of Pre-Intervention Thrombus Migration in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Background: In patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion (LVO), between initial CTA/MRA and catheter angiography performed for intervention, the occlusive thrombus may persist unchanged, fragment and migrate distally, or resolve completely, with or without bridging intravenous fibrinolytic treatment. The frequency, predictors, and outcomes of pre-intervention thrombus migration not been well delineated. Methods: We analyzed a prospectively maintained registry of AIS-LVO patients at an academic medical center over a 2.8 year period (Dec 2014-Oct 2017). Comparing occlusion sites on arrival CTA/MRA with immediately following interventional angiogram, patients were classified as having: 1) thrombus persistence (TP), 2) thrombus migration (TM), or 3) thrombus resolution (TR). Results: In the 220 patients, mean age was 70.7, 42.7% were female, NIHSS was 13.8, onset to first imaging was 156 minutes, and initial occlusion sites on MRA/CTA were: ICA-20.5%; MCA-67.3%; VA/BA-12.3%. Frequencies of thrombus evolution patterns were: TP-59.5%; TM-30.5%; TR-10.0%. On multivariate analysis, independent predictors of TM were: higher NIHSS (OR 1.06 per 1 pt), cardioembolic mechanism (OR 2.40), and longer time from last known well to first CTA/MRA imaging (OR 1.08 per 60 min). While rates of substantial reperfusion (TICI 2b-3) were similar (85.2% vs 83.7%), patients with TM rather than TP had lower rates of excellent reperfusion (TICI 2C-3), 24.1% vs 44.2%, p = 0.02. Symptomatic intracranial hemorrhage occurred more often in TM than TP, 17.9% vs 8.4%, p = 0.05. In multivariate analysis, TM was independently associated with reduced rates of good functional outcome (mRS 0-2), both at discharge (OR 0.41, 95% CI 0.19 to 0.90; p=0.03) and at 3 months (OR 0.43, 95% CI 0.19 to 0.94; p=0.03). Conclusions: Early TM between initial noninvasive imaging and interventional angiography occurs in nearly one-third of patients, is paradoxically associated with poorer outcomes, including more symptomatic hemorrhage and reduced final functional independence. Better understanding of dynamic clot changes early after arrival and their effects on outcome may aid further development of reperfusion therapeutics.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.WP174
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 8
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    Hemodynamic Features of Symptomatic Vertebrobasilar Disease
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. 7 ( 2015-07), p. 1850-1856
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. 7 ( 2015-07), p. 1850-1856
    Abstract: Atherosclerotic vertebrobasilar disease is an important cause of posterior circulation stroke. To examine the role of hemodynamic compromise, a prospective multicenter study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), was conducted. Here, we report clinical features and vessel flow measurements from the study cohort. Methods— Patients with recent vertebrobasilar transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral or basilar arteries (BA) were enrolled. Large-vessel flow in the vertebrobasilar territory was assessed using quantitative MRA. Results— The cohort (n=72; 44% women) had a mean age of 65.6 years; 72% presented with ischemic stroke. Hypertension (93%) and hyperlipidemia (81%) were the most prevalent vascular risk factors. BA flows correlated negatively with percentage stenosis in the affected vessel and positively to the minimal diameter at the stenosis site ( P 〈 0.01). A relative threshold effect was evident, with flows dropping most significantly with ≥80% stenosis/occlusion ( P 〈 0.05). Tandem disease involving the BA and either/both vertebral arteries had the greatest negative impact on immediate downstream flow in the BA (43 mL/min versus 71 mL/min; P =0.01). Distal flow status assessment, based on an algorithm incorporating collateral flow by examining distal vessels (BA and posterior cerebral arteries), correlated neither with multifocality of disease nor with severity of the maximal stenosis. Conclusions— Flow in stenotic posterior circulation vessels correlates with residual diameter and drops significantly with tandem disease. However, distal flow status, incorporating collateral capacity, is not well predicted by the severity or location of the disease.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.115.009215
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 9
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    Abstract 1910: Hyperperfusion in Acute Ischemic Stroke: Serial Arterial Spin-Labeled MRI of Reperfusion and Hemorrhagic Transformation
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: Arterial spin-labeled (ASL) MRI facilitates repeated noninvasive evaluation of cerebral blood flow without the use of contrast. Hyperperfusion may be readily detected with ASL and serial imaging may therefore chronicle the dynamics of territorial perfusion from acute to chronic phases after stroke. We characterized hyperperfusion on ASL in a prospective series of acute ischemic stroke patients, describing the clinical correlates, time course and association with reperfusion hemorrhage. Methods: A consecutive series of acute ischemic stroke patients admitted during a 1-year period were evaluated with pseudo-continuous ASL with background suppressed 3D GRASE (delay=2s, matrix=64x64; 26 slices, resolution 3.4x3.4x5mm, scan time 4min). Post-processed ASL CBF maps were visually inspected for detection of hyperperfusion. DSA measures of collaterals and reperfusion were scored when available and hemorrhagic transformation (HT) was graded on GRE in all 198 cases. Univariate and multivariate statistical analyses delineated clinical correlates, timing and other imaging features of hyperperfusion. Results: Among 198 patients, mean age was 69.4±15.7 years and 48.5% were women. Among 77 with serial ASL MRI, interval from initial to follow-up MRI was median 25.0 (IQR 10.3-53.9) hours. Hyperperfusion was detected in 15/198 (7.6%) patients at baseline and 30/77 (39.0%) at follow-up. Trajectories included 7/77 (9.1%) with hyperperfusion at both baseline and follow-up and 38/77 (49.4%) showing hyperperfusion at any timepoint during admission. Hyperperfusion correlated with achievement of reperfusion among patients undergoing endovascular therapy (OR 6.5, 95% CI 1.82-23.25, p=0.018) and history of atrial fibrillation (OR 4.4, 95% CI 1.9-10.6, p 〈 0.001). Analysis of the 42 cases with DSA revealed that hyperperfusion was most common in patients with poor collateral grade followed by more complete TICI reperfusion scores. Overall, HT affected 57/198 (28.8%), including 35/198 (17.7%) HI1, 11/198 (5.6%) HI2, 8/198 (4.1%) PH1 and 3/198 (1.5%) PH2. Multivariate analyses revealed that hyperperfusion at any timepoint was a potent predictor of HT (OR 52.6, 95%CI 12.4-222.6, p 〈 0.001). Conclusions: Hyperperfusion in acute ischemic stroke is frequently demonstrated by ASL MRI, providing novel insight on the dynamics of reperfusion and HT. Hyperperfusion increases the risk of HT 50-fold, likely due to autoregulatory loss. Poor collaterals and sudden reperfusion in vulnerable cases such as those with atrial fibrillation may herald hyperperfusion and HT.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A1910
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 10
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    Combined Approach to Lysis Utilizing Eptifibatide and Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke–Enhanced Regimen Stroke Trial
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. 9 ( 2013-09), p. 2381-2387
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. 9 ( 2013-09), p. 2381-2387
    Abstract: In a previous study, 0.3 and 0.45 mg/kg of intravenous recombinant tissue plasminogen activator (rt-PA) were safe when combined with eptifibatide 75 mcg/kg bolus and a 2-hour infusion (0.75 mcg/kg per minute). The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke–Enhanced Regimen (CLEAR-ER) trial sought to determine the safety of a higher-dose regimen and to establish evidence for a phase III trial. Methods— CLEAR-ER was a multicenter, double-blind, randomized safety study. Ischemic stroke patients were randomized to 0.6 mg/kg rt-PA plus eptifibatide (135 mcg/kg bolus and a 2-hour infusion at 0.75 mcg/kg per minute) versus standard rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracranial hemorrhage within 36 hours. The primary efficacy outcome measure was the modified Rankin Scale (mRS) score ≤1 or return to baseline mRS at 90 days. Analysis of the safety and efficacy outcomes was done with multiple logistic regression. Results— Of 126 subjects, 101 received combination therapy, and 25 received standard rt-PA. Two (2%) patients in the combination group and 3 (12%) in the standard group had symptomatic intracranial hemorrhage (odds ratio, 0.15; 95% confidence interval, 0.01–1.40; P =0.053). At 90 days, 49.5% of the combination group had mRS ≤1 or return to baseline mRS versus 36.0% in the standard group (odds ratio, 1.74; 95% confidence interval, 0.70–4.31; P =0.23). After adjusting for age, baseline National Institutes of Health Stroke Scale, time to intravenous rt-PA, and baseline mRS, the odds ratio was 1.38 (95% confidence interval, 0.51–3.76; P =0.52). Conclusions— The combined regimen of intravenous rt-PA and eptifibatide studied in this trial was safe and provides evidence that a phase III trial is warranted to determine efficacy of the regimen. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00894803.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.113.001059
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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